WASHINGTON -- The proposal by the Centers for Medicare & Medicaid Services (CMS) to pay physicians less for some Medicare patients' complex office visits hasn't gotten any more popular over time.

Under the proposed rule that CMS issued in mid-July, evaluation and management (E/M) reimbursement codes for Medicare would be streamlined by having "new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services," the agency said in a fact sheet posted on its website.

CMS positioned this change as a paperwork reduction for doctors, noting that it included a "minimum documentation standard" for a level 2 visit "where Medicare would require information to support a level 2 CPT visit code for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework, or, as proposed, medical decision-making to document E/M level 2 through 5 visits," CMS said.

"In cases where practitioners choose to use time to document E/M visits, we propose to require practitioners to document the medical necessity of the visit and show the total amount of time spent by the billing practitioner face-to-face with the patient," the fact sheet continued. Although physicians might want to include additional information for clinical or legal reasons, "we would only require documentation to support the medical necessity of the visit and associated with the current level 2 CPT visit code."

The agency estimated that making these changes to E/M coding will save providers 51 hours per year, an amount that CMS Administrator Seema Verma said was "one of the most significant reductions in provider burden undertaken by any administration."

Physician organizations and other healthcare groups did express appreciation for the agency's efforts to cut the paperwork burden. "We are grateful for your efforts to simplify these requirements and reduce their associated red tape," read a letter to Verma sent on Monday and signed by the American Medical Association (AMA), the American Academy of Family Physicians, the American College of Cardiology, and more than 160 other medical organizations.

But the groups weren't happy with compressing the office visit payment categories. "We oppose the implementation of this proposal because it could hurt physicians and other healthcare professionals in specialties that treat the sickest patients, as well as those who provide comprehensive primary care, ultimately jeopardizing patients' access to care," the letter stated.

Another letter, sent to Verma on Tuesday by a group of more than 120 mostly neurology and rheumatology organizations, expressed similar sentiments. "The proposals to consolidate the billing codes for physician evaluation and management so as to pay the same amount for office visits regardless of the complexity of the patient would cut payments for visits that are currently reimbursed at higher levels than simple or routine office visits, penalizing doctors who treat sicker patients or patients with multiple conditions," the letter said.

"It is important to note that even small estimated changes in reimbursement will be magnified after physicians or their employers cover overhead business expenses," it continued. "Additionally, payments from newly proposed add-on codes, which have been put forward with the intention of protecting complex care by making up for severe cuts, would not be sufficient to ensure continued patient access, and moreover the application of new codes to some specialties and not others would effectively result in CMS picking winners and losers."

There could be consequences for patients as well, the letter said. "To offset the reimbursement cut, some physicians may spend less time with their patients and limit each office visit to one or two problems, forcing patients to return for a second additional visit to address additional medical issues ... We are also concerned that this proposal would incentivize physicians to cherry-pick healthy patients to avoid financial losses. It would also severely exacerbate physician shortages by discouraging young physicians from going into careers that provide complex care."

But the group does propose a solution as well. "Given the negative impacts of this well-intentioned proposal, we ask that CMS not finalize this concept as proposed, and instead urge CMS to work with stakeholders to identify alternative approaches that would accomplish its goal of reducing paperwork and administrative burden without endangering patient access to care."

Asked for a response, a CMS spokesman said in an email that the agency "has been extensively engaged in seeking input from the medical community on this proposed rule and we look forward to receiving and reviewing the comments."

He said CMS has a long history of participating in stakeholder workgroups, including the AMA's RBRVS Update Committee, which plays a major role in setting reimbursement rates under Medicare's fee-for-service system.

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